Salivary glands 2 Flashcards
How much saliva is produced in total and what % is from each salivary gland
1L/ day
70% parotid
25% submandibular
5% sublingual and minor salivary glands
What are the components of saliva
- Water, Nacl,HCO3(Buffer)
-Enzymes: amylase, lysoszyme, perioxidase - Immunoglobulins (IgA- secretory antibiody for mucosal immunity)
(IgG related to systematic immunology)
pH= 8
where is saliva produced?
acini
What cells are present in acini
serous (produces thin watery- parotid)
mucus (produces thicker mucus - sublingual)
Where is saliva stored
in ducts- vary in size & drain towards duct orifices
What type of saliva is produced by the parotid
thin watery saliva (serous> mucus)
What type of saliva is produced by sublingual gland
thick mucus
What type of saliva is produced by submandibular
Serous= Mucus
What do salivary glands contain
- Vessels
-Lymphatics
-Lymphoid tissue
What are salivary glands controlled by & how is it stimulated
Parasympathetic (most of flow of saliva) and sympathetic nervous system (composition)
trigger: taste/ smell stimulates salivary nuclei
- trigger causes salivary glands to produce saliva in rest and digest
What is the neurone pathway for submandibular gland stimulation
- Salivar nucleus
- Chorda Tympani (Vii- also carries taste)
- Lingual nerve
- Submandibular ganglion
- Submandibular gland
What is the neurone pathway for parotid gland
- salivary nucleus
- IX- glossopharyngeal
- Otic ganglion
- Parotid
What is the mechanism for salivary glands acini to produce saliva
Cholinergic nerurotransmission: similar to neuromuscula junction
- acetylcholine is released into space between end plate and receptor
- ActH binds to receptors trigger intracellular processes (causing release of saliva)
How can excess saliva be treated?
Botulinum toxin (botox- typically used to reduce appearance of wrinkles and muscle spasms)- less saliva is produced
- central inhibition (antimuscarinic effect) e.g antidepressants
When is excess salivia considered ‘normal’
Normal drooling :when children, when sleeping, in reduced consciousness, dementia, learning difficulties, head and neck surgery/ pathology
What is the consequence of excess saliva
eczema/ skin rash (due to bacteria/ enzymes)
management: treating eczema & keeping skin free from saliva
What conditions are associated with true excess saliva
- drug poisoning
- Parkinsons
-Myasthenia gravis (neurological problem treated with cholinesterase inhbition- more acetyl choline is present at the nerve junction and so stimulates saliva - psychosis
-dementia
poisons: mercury, insecticides, heavy metal, nerve agents
sore mouth: lumps, ulcers- trigger salivary nuceli
What are the causes of a dry mouth and how is a dry mouth measured?
Causes of dry mouth: anxiety, dehydration, drugs, salivary gland damage
assessed by Challecombe scale
What drugs cause a dry mouth
antidepressents (nortiptyline, amitrypts)
- antihistamines
-diuretics
-PPis
What are causes for Salivary gland damage
- sjogrens syndrome
-radiotherapy
-sarcoidosis
-HIV
-Hep C
-Cystic fibrosis (affect secretions)
What is saliva like in cystic fibrosis patients
Less watery saliva and more mucousy
What are the consequences of a dry mouth?
- Mechanical (affects swallowing, speech, denture wear and debris in mouth)
-loss of taste
-caries & periodontal disease
What oral problems (diseases/ features) are associated with a dry mouth
- dry lobulated tongue
-Angular chelitis - Candidiasis (erythematous thrush/ discomfort/ taste chabge)
- caries, perio, lack of taste
How do you investigate a dry mouth?
- Clinical examination (is the mouth dry)
- Diagnosis of why it is dry
- 3 months+ of a dry mouth suspect sjogrens
How can you objectively assess the level of saliva produced?
- Saliva flow rate ( see in a cup how much saliva they produce)
- Stimulated parotid saliva- Use carlson-crittenden cup (sits over parotid)
Stimulate saliva with citric acid on tongue
What imaging techniques can be done to investigate saliva production
Sinalography:
Use dye to see salivary glands- stones can be seen
Ultrasound : bounce soundways off tissues
Water Filled can pass sounds ways easily through them→ stones can be see,
Stricture of duct: thinner and more constricted
What is meant by Punctate sialectasis and how can it be detected
- balls of dye at end of tree of salivary ducts)
- Sign of sjogren’s disease
- can be seen via sinalography & ultrasounds
What is primary sjogrens syndrome?
dry mouth and dry eyes, no connective tissues disease (RA/ CTD/ SLE )
What is secondary sjogrens syndrome?
Secondary sjogrens syndrome: dry mouth, dry eyes, autoimmune disorder RA/ CTF/ SLE
What is the cause of sjogrens syndrome & incidence?
Autoimmune disease causing destruction of salivary acini- Autoantibodies produced by the body
Can affect other tissues (glandular tissues)
Incidence:
50 per 100k
F:m = 10:1
Peak age of 50-60 years
HLA association: as connective tissues
How is sjogren’s syndrome diagnosed?
Oral symptoms:
- dry mouths daily 3/12 m
- Persistent/ recurrent salivary gland swelling
- Need to take water to swallow
Eye symptoms→ dry eyes daily 3/12m
-sand/ grit sensation in eyes
- Tear substitutes/ drops >3/day
Objective criteria
Salivary flow
Schirmer test: tears on blotting paper, measure speed tears flow down
scarring/ ulceration of cornea
Auto-antibodies
Labial gland biopsy: looking for focal inflammation infiltrate
What are the complications of sjogrens syndrome?
dental complications: reduced QoL, Caries, perio
eyes: scarring & reduced vision
lymphoma: 5% risk of lymphoma
What is the management of dry mouth/ salivary glands obstruction
- Advise to see ophthalmologist
- Educate lymphoma risk
- Specialist referral
How can symptoms of sjogrens syndrome be managed
- Diet, Fluoride, OHI
- Manage fungal/ bacterial infectionsm
- Stimulate Saliva
- Sugar free sweets/ chewing gums
- Sialogogues: pilocarpine
- Artificial saliva
What are the causes of mechanical blockages of salivary glands
Stone/ strictures→ due to protein/ minerals together
- Most commonly submandibular
- Usually affect one gland at a time
-Saliva flow cannot escape and increase pressure causing swelling
How can salivary gland blockages be investigated
Investigate if occurs during meal times (on tasting/ thinking of food)
- O/E: no saliva draining from duct when message, feel stones in the floor of mouth
- X-rays can show up
What are the treatment options for salivary gland blockages
- Papillotomy:
- Duct dilation via lacrimal probes:
- Basket retrieval:
- Sialography:
What is meant by Papillotomy
ncision at duct orifice to extract
What is meant by Duct dilation via lacrimal probes
indications : if duct is too small
Introduce lacrimal probes (smallest to largest)
What is meant by Basket retrieval
indications: if stones are further back
-Sialendoscopy is introduced into duct, stone is trapped by basket and removed out
What is meant by Sialography
pump small volume of liquid under pressure, dislodge stone
What are the causes of acute infections of salivary glands
Caused by Reduced salivary flow rate:
- Less saliva, reduced pressure gradient, bacteria can move from mouth into salivary orifice into gland causing an infection
Who do acute salivary gland infections affect?
Elderly, young, dehydration
What are the symptoms of acute infections of salivary glands
Feel acutely unwell, high temperature, raised WCC, swelling over gland, hot, red swelling
How are acute infections of salivary glands treated
rehydrate, analgesia, antibiotics
What are the symptoms of chronic infections of salivary glands
little/ no symptoms, recurrent swelling, pain, affect at meal times due to scarring
Each time occurs, more scarring
How are chronic infections of salivary glands treated
supportive (removal of glands parotidectomy, remove damage gland), antibiotics, surgery: difficult due to scarring
What is sialosis & its causes
Painless swelling of the glands (usually parotids & bilateral)
Causes: diabetes, alcohol, drugs
How is sialosis treated?
Treatment not necessary, remove gland
What is a cyst?
pathological epithelial lined cavity
What are the 2 types of salivary gland cysts
- Mucus retention
- Mucus extravasation
What is a mucus retention cyst?
blockage of salivary gland within gland/ duct minor glands
What is a mucus extravasation cyst?
escape of saliva from traumatised gland/ ducts minor glands/sublingual
What is a ranula & what is the appearance
-occurs in floor of mouth
Non-developmental cysts
Looks like a frog belly (latin for frog)
Appearance: Blueish, firm, feel full of fluid, round and smooth, floor of mouth
What is a plugging ranula & what is the appearance
(extends through mylohyoid muscle into neck)
Neck swelling
Has 2 elements: intra-oral and extra-oral
Extra-oral: in the neck
What is the treatment of a plugging ranula
remove intra-oral/ extra-oral element
Operation on mouth / neck
If do one it will come back
How can you differentiate between mucus retention/ extravasation cysts
cannot tell unless remove
What is a lip mucocele?
- what is the appearance?
blockage of minor salivary gland
-occur lower lip
- if upper maybe minor salivary gland tumour
appearance: painless soft fluid filled swelling, may appear bluish
What is the treatment for lip mucoceles?
Cryotherapy: (CO2/ liquid nitrogen to cool down probe end), forms iceball, ice crystals within tissues form, crystals burst cells and damage them, cyst is destroyed
Excision: cut in the lip, risk of recurrence, scar/ swelling/ bleeding/ bruising
